Final semester, good grades, but I feel like I need remediation.

[simply_viki]

I do well in school. I test well, consistently. The whole brain-dump after tests, though? Yeah. Making it worse is the fact that I'm in the part time program at my school, so there are many things that I haven't encountered in clinicals yet... and it may have been two years since I learned about it!

Low moment in clinicals yesterday in the ER: A patient came in, 18 y/o male, complaining of abdominal pain. When asked where it was and how bad it was, he pointed to the epigastric area and said it was 5/10. I had hooked him up to the monitor and had just gotten out my stethoscope when the nurse came in and took over (poor lady must have been so sick of me by this point... I'd utterly failed at a Foley insertion earlier and kept on asking questions). Turned out his pain was actually in the lower right quadrant, was worse when she had him bend his knee and applied pressure to his foot, and was tender to palpation. As we headed towards the nursing station, she asked me what I thought he might have, specifically as a male patient. I was stumped. "Uh... maybe a hernia?" She just looked at me, and then started having me recite the parts of the intestinal tract. "Let's see... duodenum, jejunum, ileum... colon..." She stopped me, and asked what I was missing. Can you believe I completely blanked out on THE APPENDIX???:smackingf

That's a perfect example of the huge gap between my learning and the actual experience, though. GI was taught in Summer 2009. I haven't had a single appendicitis case in all my clinicals. Oh, I could tell you all about pancreatitis and cholecystitis... that was just last semester, and I've actually had a few of those cases in clinicals. But I sure didn't luck out on appendicitis.

And then there's skills. Oh gosh. Take the Foley, for example. I did that maybe a total of 3 times in lab, including when I was tested. As part time students, we don't have access to the lab other than during scheduled class time (it's closed during the evening when we're not at work), so that was all I had the chance to do. And the opportunity never presented itself in clinicals. A couple of times I had a patient who already had a Foley... but no patient who needed one inserted until yesterday. And boy, that was a FAIL. I drew a blank right from the moment I opened the sterile package, couldn't remember what anything was for... the nurse had to prompt me along all the way through it. The iodine swabbing stuff was different in that kit than in the kits we had in lab - in lab we had cotton swabs in a packet of iodine. This kit had an iodine packet you squirted onto a bunch of cotton balls and it came with a little set of tongs (calipers?) to pick up the cotton balls with. I started out holding the tongs upside down, first of all, and kept getting the cotton balls stuck on my gloves (who knew iodine on cotton was soooo sticky?!). The nurse told me to forget the tongs and just pick up the cotton balls with my hands, so I did... and then I forgot (I don't even want to admit this, really) the whole "front-to-back thing. No kidding. I can remember that in a test, but apparently in person it just flees my mind. The nurse still didn't give up on me, though, and just reminded me to wipe front to back, so I did. I kept having trouble with the sticky cotton balls. Finally, I couldn't find the patient's urethra. Try as I might to get in there with my fingers, spread it apart and look, I couldn't see anything but labia, the patient's legs kept contracting close together no matter what we said, and I know I broke sterility a few times trying to keep her legs out of the way. I mean, I know where the urethra is in relation to the privy parts and lady parts, but if I can't see either, what am I supposed to do? Finally, the nurse took over and did it herself. I just wanted to find a good hole in the ground somewhere and bury myself in it.

And those are just a couple of examples.

Oh, and my school didn't teach us how to insert IVs until this semester, and I got to try it ONCE, but messed it up that time, too. And we hadn't been warned that we'd be practicing that in lab, otherwise I would've read about it and probably would've done better. We're all expected to successfully insert an IV in addition to a few other personally identified objectives (mine include inserting a Foley... so I'd better get better at that fast) by the end of the semester.

Then we graduate! Turned loose into the world of nursing with barely a handle on basic skills. I feel so inept at everything that I sometimes wonder if there's any way I can just take the whole program over again, even though I have A's and B's in every single class. I kind of feel like it would be unethical of me to even attempt to practice as a real nurse, but I don't know how I'll learn if I'm not actually in the field and I don't really know what options I have. Can A and B students request remediation? Would I be laughed off the block? Is that even likely to help? I'm at the end of the program and I'm just sort of panicking that I'm going to be a horrendous nurse.

[Missy77]

I absolutely felt the same way when I was in my nursing program. Not enough training in skills and the entire program just felt rushed. Have you tried applying to a summer nursing externship program? This will give you more hands on experience with patients and some programs offer educational programs. Also everyone needs a refresher course and this is why hospitals have continuing education classes for nurses to keep the hospital staff up to date and current in skills and new procedures. Some local community colleges offer refresher courses for nurses usually under continuing education section. Some student/professional nursing organizations might offer training you could look into once you have membership. Find a local chapter in your area. Hope this helps.

[Boog'sCRRN246, RN]

I think what would be worse is if you graduated feeling like you know everything. What you described is not uncommon at all. That's why decent employers (those that will hire a new grad these days anyway) have such a looooooong orientation/preceptor period before you are turned loose on your own.

Personally, I think your school has done you a disservice by waiting until the last semester to teach IV insertion. I guess I was lucky with my clinical experiences; I had instructors who sought out skills for us to practice, even if it meant going to another floor to do it. Also, other nurses on the floors we were on kept their ears open for patients who had something that a student nurse might have needed to practice.

Do you have open lab hours? I would definitely make it a priority to go and practice and keep practicing until you get it down. Also, during clinicals, if you're allowed, ask other students/nurses if they know of any patients that need a Foley/IV start/etc.

Honestly, I really wouldn't get too stressed out over it. Obviously, you should at least have an idea of how to perform a skill before you graduate, but no one is expecting you to be an expert at it.

[rdsxfnrn]

The first thing most people figure out right before graduation is that they don't know jack! Finish your classes, pass NCLEX, and you will learn the rest on the job. That's what orintation is for. :)

[simply_viki]

Thanks for the replies, you guys.

Missy77 - I hadn't heard of Summer Externships until you just mentioned it. I did a quick Google search on it, though, and it looks like most places in my area are just looking for BSN grads, not ADN. Boo.

Boog'sGirl724 - Thanks. I also spoke to a former classmate of mine who started the program with me, but switched to full-time about halfway through and has since gotten her RN and was lucky enough to land a job in ER as a new grad! She reassured me that she felt the same way, it's normal. Whew. I guess that helps, a little.

I definitely agree on the disservice thing... at this point, I was starting to worry they were never going to actually teach us at all. It was in clinical orientation that I piped up that we hadn't learned to do IV insertions, and that's when they decided to take the whole group over there to do a quick run-through. So... yeah.

I'm going to call the lab manager to ask her what their hours are. Most of the campus is closed by about 4:30, except the library and tutoring center (which unfortunately does not include a lab)... and I get out of work at 4:30. If it's open in the evenings, I'll definitely go at least once. I've been trying to use the evenings for practice NCLEX questions we have to turn in each week, but I think I can just do double the questions another night or something.

rdsxfnrn - you sure aren't kidding!